What Does an Ideal Healthcare System Look Like?

Austin Frakt and Aaron Carroll recently approached me about a New York Times UpShot piece aiming to rank eight healthcare systems they had chosen: Australia, Canada, France, Germany, Singapore, Switzerland, the United Kingdom, and the United States. This forced me to think about a pretty fundamental question: what do we want from a healthcare system?

I would argue that most people want a healthcare system where they can get timely access to high quality, affordable care and one that also promotes innovation of new tests and treatments. But underlying these sentiments are a lot of important issues that need unpacking. First, what does it mean to be able to access care when you need it? A simple way to think about this is being able to see a doctor (or other healthcare professional) quickly and easily and in cases where there are follow-on tests, procedures, and treatments, you can get them without much delay. This brings up one important point: while experts often discount the importance of timeliness, regular people generally don’t: anyone who has waited weeks or months for a follow-up after an abnormal test result or to get a needed surgery knows that waiting times are not just an inconvenience. Delayed access can be stressful, agonizing and in some instances, downright harmful.

Beyond access, of course, we want care we can afford. Almost all of us need some sort of insurance that would pay for an unexpected, catastrophic healthcare expense (like spending a few weeks in an ICU). Most of us need some sort of financial coverage for other, slightly less expensive services such as an MRI or a knee replacement. And even still, some of us will struggle to pay for simpler things like doctors’ visits and need financial help there as well.  There is broad consensus that we want a healthcare system where people aren’t denied the services they need because they can’t afford them.

While accessibility, timeliness, and affordability are key, there are other aspects of care that get less attention but are just as important: we want care that is safe and effective and produces the best outcomes possible.  It’s great if you can have timely cardiac surgery and pay little or nothing out of pocket. But if you die unnecessarily from a preventable error, you didn’t get what you needed from the healthcare system.

Finally, we want a healthcare system that creates new knowledge so that we get better at caring for sick people. One of my earliest memories of medical school was caring for a young woman, an artist with two small children, who died of a complication of chronic myelogenous leukemia after a bone marrow transplant. Today, her disease could have been managed by a simple, daily pill that has turned CML into a chronic, yet manageable disease.  A system that generates new therapies that save lives is critical and its importance is often overlooked when assessing health system performance.

Health System Organization

So what is the ideal way to organize a healthcare system to accomplish these goals? One school of thought believes that market-based systems are the solution because they rely on competition, customize care for individuals, keep prices down, and allow the highest quality providers to flourish. For others, the answer is a government-run, single-payer system where everyone has equal access, gets comparable quality, and patients don’t have to worry about costs because the government takes care of it. While either approach can be supported with selected data and facts, as I have looked at health systems from around the globe, one theme becomes obvious: systems organized very differently can achieve comparable levels of performance and no single approach consistently outperforms others.

So which countries have the best systems? As the UpShot piece outlines, we did a tournament-style competition where in each round, we had to pick winners and losers.  At the end, we were also asked to rank the selected 8 countries based on our overall assessment. To do so, my approach was simple. Health systems should be judged not by how they are organized (i.e. markets or government) but what they produce. How well does it do what a healthcare system ought to do? So that’s the approach I took.

Evaluating Health Systems

That leads us to the next question: what metrics should we use? If you made it to the first day of a health policy 101 class, you learned about two metrics: per capita spending and life expectancy.  If you made it to the second  class, you learned that unfortunately, these are far too crude to tell you much about health system performance and do not help generate an actionable set of policy prescriptions.  Health care spending is driven by many factors, including what is encompassed in spending calculations (research and development? medical education?) and prices (if one country pays its nurses half as much as another – does that mean the first is twice as efficient?).  Life expectancy is even more complicated as it is driven in large part by behavior, lifestyle, and genetics of the underlying population. As Irene Papanicolas and I point out in our recent JAMA piece, drawing these boundaries when comparing healthcare systems is important.

So if we can’t just look at those metrics, what else should we examine? While one could evaluate literally hundreds of metrics, I prioritized 16 (see Table 1).

None of these are perfect but they seemed reasonable to me – a few on access, quality, cost and innovation. Ultimately, I was interested in assessing performance in areas that are clearly within the purview of the healthcare system – how many people are covered and covered for what? How quickly can you see someone when you’re sick? How good is the system at taking care of you when something terrible happens, like you have a stroke or a heart attack? Does the system generate lots of innovation so that everyone’s care gets better over the time?  I tried not to overly weigh any one of these but tried to look at them holistically.

My Rankings

Based on these measures (for country data, see Table 2), my ranking of the selected health systems is as follows:

  1. Switzerland
  2. Germany
  3. U.S.A.
  4. U.K.
  5. France
  6. Australia
  7. Canada
  8. Singapore

A few caveats.  First, these are all very good healthcare systems – and we’re generally comparing systems that are far superior to much of the rest of the world. Second, there was rarely a clear winner in head to head competitions.  Switzerland and Germany both have excellent systems and reasonable people could draw a different conclusion from the same data. I struggled among the U.S., France, Australia, and the U.K., all of which had clear strengths and clear challenges. Singapore lagged behind in large part because there is so little data about their performance and lack of data means it might be better than it looks, or it could be worse. I just don’t know.

The ranking of the U.S. above places like France and the UK may be surprising. Some people will point, rightly, to the fact that the U.S. has the highest spending in the world yet still has people who are uninsured. The healthcare spending problem of the U.S. is largely a political choice – we have extraordinarily high prices on everything from physician salaries to pharmaceuticals.  While some of these high prices may spur innovation (i.e. pharmaceuticals), the cost of spending nearly 20% of our GDP on healthcare means less money for everything else. We could do better with different policy choices.

On the issue of universal coverage, things are a bit more complicated. While its narrowly true that the U.S. is the only country here without universal coverage, it’s too simplistic.  First, 91% of Americans are now insured (thanks in part to the ACA).  Some countries have universal coverage for their citizens but not necessarily for immigrants or other groups. Second, it is important to consider what is actually covered.  While most Americans can get access to the latest treatments, in many countries, access to the most expensive therapies can be difficult or non-existent.  I don’t know if we will get to 100% coverage but we are inching towards it and I hope that with the next set of policy reforms, we can get into the high 90’s.  And that would be good.

Finally, if you take a big step back and look at the data, Americans do better than average in timely access, especially to specialty services and “elective” surgery (which is often not that elective).  They tend to be among the leaders in acute care quality, when healthcare means the difference between life and death, although the quality of primary care could surely be better.  And America is the innovation engine of the world, pumping out new drugs and treatments that benefit the whole world.  All of that earns America a high rank in my book – behind Switzerland and Germany but ahead of others. You can disagree but overall, while the U.S. healthcare system has a lot of work ahead, we should not overlook its strengths – and they are sizeable.

So here’s the big picture: when it comes time to measure health system performance, it’s important to think about boundaries (what is the responsibility of the healthcare system and what isn’t).  It’s also important to consider whether the system is delivering what people need: coverage of a broad range of services, especially those that are important for the sickest among us, timely access to affordable, high quality care, and innovation that ensures care gets better over time.  For most people, whether the system is market-based or government-run matters a lot less than whether it’s meeting their needs. And that’s the way it should be.

What Does an Ideal Healthcare System Look Like? published first on http://ift.tt/2rKD0bD

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How Consumers Are Shaping the Next Gen Wellbeing Experience

Our day-to-day interactions with technology are changing expectations and aspirations for almost every touch point in modern life. We want instant feedback and action at the push of a button, from the digital shopping cart to the doctor’s office. That is part of why there is a constant stream of new apps and tech services being released across every industry, including wellness. But the barrage of options can be a problem of its own nature.

To better understand what people want and how to deliver resources that resonate and stick, we spent time studying how real people engage (or don’t) with personal health and well-being. What we found was instantly familiar yet full of deeply personal insights that made the struggle real and the solution obvious.

So often we design towards an end-goal or finish line. As we were reminded through our research, health is not static. For the healthy, those with chronic conditions, those actively managing to avoid serious health issues, the issues are all the same: it’s a challenge to live your healthiest life every day. It’s a daily struggle to avoid the foods we shouldn’t eat; it’s a daily struggle to exercise; it’s a daily struggle to live in the “white space” between doctor appointments.

To help people, we need to not only design solutions that fit into their daily lives with convenience and ease, we need to give them help that works in real life. We need to design technology that works alongside people through the ups and downs. This can be tough for well-being programs as we often need to fit these tools alongside program components driven by larger initiatives and deadlines, but it can be done.

A good place to start rethinking program design is understanding the three simple criteria for a consumer-friendly program. Check out our three quick tips to learn the basics for designing a health and well-being program that resonates with employees by putting real people at the center of every interaction.

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Madhavi Vemireddy, MD, is Chief Medical Officer and Head of Product Management, ActiveHealth Management

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Forget Trump. The 2020 Election Will Be About Single Payer.

Last week, the Senate Health, Education, Labor and Pensions Committee wrapped up hearings focused on stabilizing the individual insurance market leaving unresolved an issue that separates Dem’s and Rep’s on the committee: just how much freedom states should have in managing their insurance markets. At issue are the Section 1332 waivers which allow states to reduce essential benefits in health insurance policies, thus allowing insurers to sell policies that cover less with lower premiums.

Also last week, Republican Senators Lindsey Graham and Bill Cassidy offered what they called the “last chance” for Republicans to repeal and replace the Affordable Care Act. Their bill would repeal the individual and employer mandates and replace the ACA’s tax credits, Medicaid expansion, and cost-sharing payments with block grants to states so governors would have more flexibility and authority in managing their Medicaid programs and insurance markets.

But arguably more media attention was directed at Sen. Bernie Sanders’ proposal to replace the current employer-sponsored health insurance system with “Medicare for All” which would be phased on over four years and be funded by increased employer payroll taxes and higher taxes for those earning more than $250,000. What appeared to garner the media’s attention was the cadre of 15 Democrats in the Senate and 117 in the House who endorsed his proposal, though its price tag is unknown.


The notion of Medicare for all, or a single payer system, is not a new idea. Public opinion is mixed. A Kaiser Family Foundation poll in June found 57% of Americans favor the concept of Medicare for All. An Economist/You Gov poll in April reported that 60% of Americans think “Medicare should be expanded to cover everyone”.  And polls by Politico, Rasmussen and Pew have shown favorable responses by 2 in 5. But questions about how a single payer system would work are widespread and like so many issues, complicated. Here’s my take:

The concept of a single payer system is gaining in popularity and will be the centerpiece of the 2020 Presidential election. The public’s not happy with our current system and it’s clear in polling that we’re a soft target. Insurers are not trusted, drug companies are considered greedy, hospitals are thought to be wasteful and physicians appear more concerned about their incomes and control than their patients. Those on Medicare are happier with their coverage than those with private coverage and employers are shifting more costs to their employees directly or suspending benefits altogether. And after 7 years of contentious debate about the Affordable Care Act, there’s a fundamental divide in our land: half believe healthcare a right that the federal government should guarantee and the other think the federal government, if given more control, will ruin it. The public thinks Congress is more about partisan wrangling and getting elected than problem solving so that’s where we are. But while divided about the Affordable Care Act, the majority think access to healthcare is a fundamental right and insurance coverage an advantage in obtaining it.

Tracking polls by Kaiser, Harris, Pew and others show consistent increases in the numbers of citizens who think the current system is broken—too expensive, too complicated and too focused on profit—and the majority want something better. Public opinion polls by Deloitte and others show healthcare systems in Switzerland, France, Canada, the UK and others get better grades from their citizens than does ours. So, the notion of a single payer system, though not understood, will gain momentum as a defining issue in Campaign 2020 especially among Democrats who aspire to be in the White House one day.

Acceptance of the trade-offs inherent in a single payer system will spark fierce debate. For most Americans, understanding what exactly a single payer system is and how it might work is not deep. Usually, single-payer healthcare is described as a healthcare system financed by taxes that covers the costs of essential healthcare for all legal residents. Alternatively, a multi-payer system, like what we have in the U.S., is one in which private individuals or their employers buy health insurance or healthcare services along with purchases made by the government for designated populations.

In some single-payer systems, like the Canadian system, private hospitals and doctors contract with the provincial government to provide care for patients. In others, like the U.K. National Health Service, providers are employed by the NHS to provide services to patients with allowance for outside work with private patients. And there is wide variety in single-payer models among the developed healthcare systems in Europe, North America and South America, parts of Asia and the Mediterranean.

In the U.S., our national discussion about a single payer system will likely focus in two broad areas:

  1. Costs: in single payer systems in developed countries, the legislative process determines priorities for budgeting, usually tied directly to the growth rate of the economy and an acceptable investment in healthcare. Healthcare is usually 6-13% of a country’s GDP (vs. 18% in the U.S.) and funding includes social services in addition to direct patient care activities. And in most single payer systems (not all), individuals pay part of their tab and some purchase private insurance to cover their out of pocket expense or get access to services not covered by the government’s coverage.The U.S. debate will center on two issues: the relatively high prices we pay for the drugs, devices, technologies, services and facilities we use, and the medical necessity for many services provided for which evidence shows no benefit. What happens to innovation if the federal government uses its muscle to ratchet down what it pays for services and who decides what’s necessary or not? And what’s the administrative expense necessary to managing our $3.4 trillion expenditure? Senator Sanders Medicare for All has not been costed by the Congressional Budget Office but most expect it to cost more than the status quo. Some counter it will cost less because administrative costs will be half what private insurers pass through in premiums and the government will use its muscle to drive down prices for drugs and everything else it buys. But no one knows for sure.
  2. Structure: in developed single payer systems, primary and preventive health is the front door to the system. Physicians and mid-level providers authorize access to specialists acting as gatekeepers. Coordination of social services with medical care is formalized adding 3-5% to the total costs of care. A government agency/board determines priorities for the system and allocates funding accordingly. Rationing of services and programs is standard operating procedure and end of life care is less institutionalized. In the U.S., primary care is subordinated to specialty medicine unless a provider organization accepts long-term risks for a population’s costs and outcomes. And primary care is fragmented and incomplete: dental care, mental health, nutrition and health coaching are not effectively or consistently integrated with physical medicine and medication management.

    The issue will be whether and how primary and preventive health will be elevated in a U.S. single payer model and how specialty and long-term care are impacted long-term. If the appetite of American taxpayers is for modern facilities and unfettered access to specialists at will, there will be tension.

In the interim, the Affordable Care Act will be the law of the land, though with tweaks resulting from executive orders and administrative actions that address its primary aims: to change incentives from fee for service to value and to increase access to insurance coverage for those without. But attention to the allure of a single payer replacement will increase, and with it public debate about how it should be structured and what it should cost.

Forget Trump. The 2020 Election Will Be About Single Payer. published first on http://ift.tt/2rKD0bD

Diversity in Health Tech: A Non-Negotiable

The tech industry is notoriously lacking diversity. Health tech, that needs to be representative of all individuals, also lacks diversity in both the innovators creating technology and the technology targeting diverse users. There have been article after article citing the problem, but what really, can be done to close the diversity gap?

Last Fall, at Health 2.0’s annual conference, Health 2.0, with support from the Robert Wood Johnson Foundation, hosted a panel focusing on minority entrepreneurs and building tech products for underrepresented groups. The discussion that followed the panel was a passionate and thought provoking conversation. Some feedback from the panel included: “Why isn’t this discussed more often” and “There is dire need for inclusive products and support of underrepresented groups in tech”. With that feedback, and the ever discouraging research, Health 2.0 decided to do something about diversity in health tech.

In January, TECHquality, a mentorship program for individuals who are underrepresented in health tech, paired those individuals with leaders in the health tech space. Underrepresented groups include, but are not limited to: People of Color, Women, LGBTQ, Veterans, People with Disabilities, etc. With over 200 applications for mentors and mentees, 80 mentor/mentee pairs were matched based on areas of interest and expertise. After a 4-month long mentorship program, 96% of participants who met at least once a month agreed the mentorship program was worthwhile and impactful on their career and 94% of participants who met at least once a month agreed that the program matched them with a mentor/mentee that fit their area of need/expertise.

With support from the Robert Wood Johnson Foundation, Health 2.0 is excited to begin another open application for TECHquality. Potential mentees and mentors are encouraged to apply here by 10/18. The program will officially start November 2, 2017 and run through early March, 2018.

Is your organization interested in making actionable impact to close the diversity gap Partnership and sponsorship opportunities available. Email alyx@health2con for more information.

Alyx Sternlicht is a Senior Program Manager at Catalyst @ Health 2.0.

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Healthy Whole Wheat Pumpkin Walnut Bread (+ Muffins!)

Bread? Or Muffins? How about both! This Healthy Whole Wheat Pumpkin Walnut Bread and Muffins recipe will give you the best of both worlds. They’re made with white whole wheat flour, pumpkin puree, warm spices, and walnuts. We originally had this recipe scheduled to go live in a few weeks, and I just can’t stand to make…

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The post Healthy Whole Wheat Pumpkin Walnut Bread (+ Muffins!) appeared first on Fit Foodie Finds.

Healthy Whole Wheat Pumpkin Walnut Bread (+ Muffins!) published first on http://ift.tt/2rKD0bD

The Cost of Public Reporting

In an age where big data is king and doctors are urged to treat populations, the journey of one man still has much to tell us. This is a tale of a man named Joe.

Joseph Carrigan was a bear of a man – though his wife would say he was more teddy than bear.  He loved guitar playing,  and camp horror movies.  Those who knew him well said he had a kind heart, a quick wit and loved cats.

I knew none of these things when I met Joe in the Emergency Department on a Sunday afternoon.  I had been called because of an abnormal electrocardiogram – the ER team was worried he could be having a heart attack.  Not able to make sense of the story on the phone, I was in to try to sort it out.  Joe was gruff, short with his answers – but clearly something just wasn’t right.   He was only 54 but had more problems than the average 50 year old.   Progressive calcification of his aortic valve  some years ago  had caused intolerable shortness of breath resulting in  replacement with an artificial valve. Longstanding diabetes had resulted in kidney failure and dialysis,  and most recently abnormal liver tests had  revealed the presence of the early stages of cirrhosis from hepatitis C.  Yet Joe continued to live an active life – with only a tight circle of family and friends aware of the illnesses beneath the surface.

But on this particular day it was readily apparent Joe was not well.  It didn’t take long to figure out that Joe had an infection somewhere.  He had come in feeling hot at times, but having chills at others.  Review of his ECG, stored telemetry in the ER revealed a conduction disturbance not infrequently seen called a left bundle branch block, as well as a rhythm disturbance called atrial fibrillation , but no evidence of a heart attack  that had prompted the ER to call me.   I told Joe and is anxious wife that he needed to be admitted to the hospital to find where the infection may be coming from.

Joe had a number of places he could be harboring an infection.   While dialysis maybe one of the modern marvels of the world, the concept is fairly crude. In the absence of functioning kidneys an artificial machine does the work of the kidneys. Via large catheters the patient’s blood is removed, circulated through the machine and then returned to the patient.  The flow required to circulate enough blood over a course of three hours involves creation of large conduits between arteries and veins, or placement of artificial grafts.   Every access of these vessels with dialysis sessions  carries a risk of introducing bacteria into the bloodstream, making infections a common event in this population.  Complicating matters further, Joe had an artificial heart valve,  which lacking the natural immunity of native heart valves,  are especially prone to seeding by bacteria.

I told the admitting team that if no other source of infection became immediately obvious he would need an ultrasound to more closely examine his valve. That night I was called by the overnight resident in the hospital because Joe had a low heart rate. He felt fine,  and his blood pressure was OK .  I stopped a heart rate lowering medication that he had been on hoping this may be the cause.   The next morning a review of his electrocardiogram and recorded telemetry demonstrated an ominous finding – episodic heart block.   The heart’s four chambers are segregated into two small upper chambers that contain the pacemaker function of the heart and two lower chambers  that are the powerful mechanical pumps which circulate blood.   The upper chambers are electrically insulated from the lower chambers except for narrow specialized bundles of tissue that function as electrical cables.   The specialized conduction fibers form an intricate lattice that allows the normal heart to contract  in less than 100 ms.  The weak point is a narrow isthmus in close  proximity to the  aortic valve that the electrical bundles must navigate near their origin.   In Joe’s case, the electrical bundles were conducting in a stuttering fashion because bacteria was eating away at precious cardiac tissue surrounding the artificial valve.

There is only one treatment for this: surgery.  John needed a surgeon to open his chest, take out his infected  aortic valve, wash out the abscess and put another valve  in its place .

I called the surgery team immediately –  Joe was clearly a high risk case.   The  presence of kidney disease, liver disease, and prior open heart surgery were all independently high-risk markers.  Joe of course had all three.  Yet, he was an active functional 54-year-old. What was the other option? Let him die?  My initial conversation with the surgeon was a positive one, and surgery was scheduled for the following day.

The following day brought a decidedly different tone.   There was a brief discussion about a conversation with the hepatology team having changed the surgeon’s mind.  A prediction score for patients with liver disease suggested there was a 50% chance he would be dead in 6 months regardless of his current life threatening cardiac abscess.  That score seemed to be an overestimate, and hepatitis C is now a treatable illness but regardless, I pushed back and responded that the chances he would be dead in 2 weeks with his current condition was 100%.  After some more parrying back and forth – the real reason for the cold feet emerged.  Outcomes of cardiac surgery are publicly reported for all institutions and surgeons nationally, and in the state of Pennsylvania.  After discussing the case with the other surgeons at the institution, the decision at this hospital had been made: Joe had too high a chance of making the institution look bad.

How did we get here?

Public reporting

The desire for public reporting arises from an attempt to broadcast value to a public eager for information.  The Institute of Medicine’s seminal report in 1999 suggesting 98,000 patients die due to preventable medical errors every year added a sense of urgency and necessity to the push to grade providers.

Public reporting actually began more than thirty years ago – in 1984 – when the Health Care Financing Administration (HCFA), now known as the Centers for Medicare and Medicaid Services (CMS), began to publicly report the hospital mortality rates of Medicare patients.  The agency identified 269 hospitals that were outliers with regards to death rates. Although the analysis attempted to control for a variety of risk factors, it was heavily criticized and eventually HCFA stopped publishing the data.

There was no turning back though. New York state and Pennsylvania followed suit and started publicly reporting cardiac surgery outcomes.  The group in charge of reporting in Pennsylvania was the Pennsylvania Health Care Council (PHC4) -created by the Pennsylvania General Assembly with the charge of improving the quality of care and restraining health care costs.

As the HCFA learned, reporting outcomes is a complicated business.  Reporting outcomes  relies heavily on the ability to risk stratify patients.  The PHC4 struck on what is now a common model – calculate the expected mortality of each patient based on who they are and how they present and compare this to the actual reported mortality.  A number of factors are considered, and each factor is weighted with regards to its impact on mortality with surgery.

Figure 1 Clinical Predictor data table, Calculating expected mortality

The final data is then presented for the public’s perusal in an easy to understand table with actual and expected mortality for every hospital and surgeon in Pennsylvania.

The figure below demonstrates the results of three large hospital systems in the Philadelphia region.

Figure 2 . Observed/Expected Hospital mortality

Teaching to the test

Proponents of public reporting will point to improved outcomes in the era of public reporting.  In Pennsylvania, for instance, hospital mortality for Bypass (CABG) surgery dropped from 3.2% to 1.5%, and for Valve surgery dropped from 5.2% to 2.7%.

Figure 3. Cardiac surgery in-hospital mortality

The only thing more impressive than this is the drop in bypass procedures done statewide between 2000 and 2015 – which reflects an almost 60% drop from 20,029 procedures to 7,962 procedures.

Figure 4. Volume of cardiac surgery

An optimistic conclusion to draw from the data is that there are fewer unnecessary procedures being performed and those that are being done are of higher quality in a safer environment. The more troubling explanation is that surgeons are operating less, and improved mortality relates to avoiding high risk patients.

I spoke to a cardiac surgeon who had practiced in the public reporting era in New York State to ascertain his thoughts.  He told me that “without a doubt” this was a consideration that impacted who he and his colleagues would take to the operating room.  He spoke of how surgeon’s would “play the game” to improve their numbers by not necessarily denying the sickest patient, but rather waiting them out.  He gave me an example.

One of the stronger clinical predictors that impacted expected mortality was cardiogenic shock.  Cardiogenic shock refers to patients who suffer a heart attack so severe that their entire cardiac function is compromised to the point that the heart is unable to deliver an adequate amount of blood flow to vital organs such as the kidney, liver and brain.  A common approach by surgeons was to place these patients in the cardiac critical care unit or transfer the patient – the patients that survived a week were offered surgery.  The cold calculus makes sense – the expected mortality of the patient continued to be high as the patients were still labeled as cardiogenic shock – but clearly waiting allowed selection of a lower risk group of patients.

I despaired after hearing this about finding published data to support what I had heard, as I frequently find datasets simply aren’t granular enough to represent clinical practice. In this particular case I was rescued by the SHOCK registry that compared patients presenting in cardiogenic shock in NY patients and Non-NY patients.

Figure 5. Differences in treatment of Cardiogenic shock patients in NY and nonNY patients

The results are stunning.  As highlighted in the above table – the time to cardiac surgery in patients presenting with a heart attack and shock in New York State was different by almost 4 days!

The footprint of risk aversion is found even in the published data supportive of public reporting.  Peterson et. al, found declining CABG mortality in NY state with no apparent decrease in access, but troublingly, could not elucidate a mechanism for the decline in mortality.  If the point of profiling hospitals and surgeons as good or bad was to direct more patients to high performing centers, NY state officials found no evidence of migration of patients from high to low mortality hospitals.

Surveys of cardiac surgeons bear out that enmasse,  public reporting has markedly altered practice based on public reporting primarily by denying patients surgery.

Figure 6. Cardiac surgery survey results of public reporting

It used to be that a decision on surgery was between surgeon and patient.  Risks were outlined, and a decision arrived at.  The patient and doctor were in it together. Surgeons operated on high risk patients as long as they felt comfortable the patient and family understood the risks.  This construct exists no more.  Especially in an era where surgeons are employed by health care systems, the surgeon is now beholden to masters that never step into hospital rooms.  Surgeons with high mortality rates that make the institution look bad face serious repercussions, and even worse, put future employability at risk. Shared decision making is a joke – not because decision making isn’t shared but because the shared decision is between surgeon, risk score, and hospital system – the sickest patients don’t have a choice anymore.

Back to Joe

And so it was with Joe. Faced with certain death, he wanted to live, but I could not find a surgeon at my institution to operate on him.  The hyperefficient health care system moved quickly in this case.  The plan from the CCU team was now hospice/palliative care.  I couldn’t stomach it.  I told Joe that I was going to find a surgeon who would give him a shot.  So I called a center that did the most valve surgeries in the city.  This wasn’t the first time in my years in practice that a patient of mine had been turned down by a surgeon at a local institution.  Smaller volume centers are even more susceptible to risk aversion because their smaller volume amplifies the effects of bad outcomes.   The largest center in the city had bailed my patients out before from this predicament.

This time was different.  Unbeknownst to me, the academic nationally renowned busiest center in the city had been taken to task in the just published Pennsylvania public report  because they had been found to have worse than expected mortality.   The expected mortality was 1.2% – 4.1%, and the observed mortality was 4.3%.  Of 345 patients who underwent bypass surgery 15 died – one fewer death would have put the center in the expected range.  To rub salt in the wound, the local paper ran a story on the report and quoted a competing health system’s surgeon as noting the difference could relate to a minimally invasive surgery they did more of.  Not mentioned was the fact that the smaller competing health system routinely sent their sickest, most complex patients to the larger academic center.

So, the answer again was no.  Undeterred, I called Johns Hopkins next.  The cardiac surgeon patiently listened to my story – and inquired why no hospital in the city would operate on him.  I told him about public reporting, and he in turn told me about Maryland’s global payment system.  Maryland hospitals were not paid per admission anymore, they were paid a per capita amount related to the number of patients attributed to them.  The positives are that hospitals are incentivized to set up systems to keep patients out of hospitals.  The downside is that they have a powerful disincentive to take on a complicated high risk out of state patient like Joe.  I was told bluntly that Maryland was not paying for this.

I discussed the case with a prominent cardiothoracic surgeon who said explicitly –

“Politically impossible to do this case… Honestly, the big picture: he is a casualty of the public reporting system we have in the US and Pennsylvania where risk aversion is always with us.  It’s kind of sad.  There are consequences to all the decisions society makes”

Consequences.  Trade-offs.  This is decidedly not what the public hears.   The public hears things like the ‘triple aim’ – improve patient experiences of care, improve the health of populations, and reduce the per capita cost of health care.  You can have your cake.. and eat it too!  But there is a cost to all this, and it is a cost borne by our sickest, most vulnerable patients.

When CMS announced a policy in 2006 that attempted to restrict coverage of weight loss surgery to centers of excellence (COE), a study noted the unintended consequence of trying to make the surgery safer was a reduction in the proportion of minority patients receiving the surgery.  I imagine that had Joe been on the board of trustees of the hospital he would have a different set of options.

Figure 7. Proportion of minority patients offered bariatric surgery

There are so few of these patients relative to the total that they won’t move the needle when it comes to numbers population health devotees care about like life expectancy and overall cardiac mortality.  But the impact of this culture shift extends beyond the smattering of patients affected.

America has long been the envy of the world when it came to innovative surgical techniques.  The landscape for much of American history has consisted of brash physicians willing to push the envelope in dying patients with impossible odds.  Bennie Solis was one such 3 year old dying of an irreversible liver disease when he was operated on by Thomas Starzl in 1963.  Starzl thought he had perfected the technique of transplantation in dogs before attempting the feat – but he was wrong.  Bennie bled to death on the operating table, his damaged liver no longer able to make substances that would clot blood.  Starzl and the surgical team were devastated, but the lessons learned with Bennie’s death increased the chances of success for the patients that followed.  This is true of the history of every new surgical procedure attempted.  Innovation requires risk taking not risk aversion.  It is difficult to imagine a man like Starzl taking on the sickest of the sick patients at Johns Hopkins today.

The sad part is that the age of penury driving this behavior is one where overall health care spending continues to accelerate to the tune of 3 trillion dollars annually.  Our health care overlords may save some dollars on Joe, but won’t blink when spending billions of dollars on health care accountants, data entry clerks, hospital coding specialists, and any number of low yield primary care preventions geared to the worried well.

Some think the solution is simply better risk adjusting, or exclusions for centers performing at the frontiers.  Perhaps.  Or throw the whole system out and focus on the rotten apples among us.  I don’t know.  I do know that however well intentioned the practice of public reporting may be, the consequences may be severe.

I couldn’t find a surgeon who would operate on Joe.  So he died.

He never made it home to play his guitar.

The pictures and the story are presented with the permission of Joe’s wife, Debra.  Ever gracious, she hoped his story would teach us something.

Here’s hoping it will.

Anish Koka is a cardiologist in Philadelphia.  He can be found on twitter @anish_koka

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Academic Medical Careers: Splitting Streams – Segregating Non-Profit Patient Care/Medical Education from For-Profit Bio-Medical Research.

    Hopkins Alumni Careers 1980-2012. Mike Magee A fundamental principle in human physiology and homeostasis is the negative feedback loop. When the body produces too much of something, a negative signal is transmitted back to the source which limits further production until peripheral over-production declines. These systems of checks and balances have evolved over […]

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Academic Medical Careers: Splitting Streams – Segregating Non-Profit Patient Care/Medical Education from For-Profit Bio-Medical Research. published first on http://ift.tt/2rKD0bD